Failure to Maintain Investigation Documentation for Reported Incidents
Penalty
Summary
The facility failed to maintain and provide complete records of investigation documentation for reported incidents involving two residents. In the first case, a resident alleged that $70 was stolen from their possession. Upon review, the investigation file contained only the initial and follow-up self-reports submitted to the Office of Health Care Quality, with no additional documentation such as statements, interviews, in-services, or education. The Director of Nursing confirmed that no further documentation was available beyond what was provided. In the second case, another resident was found to be high, drowsy, and sleeping in a walkway, which was reported as unusual behavior. When surveyors requested the investigation documentation for this incident, facility leadership was unable to locate or provide the investigation packet. Both the Director of Nursing and the Nursing Home Administrator acknowledged that such documents should be retained for five years and made available upon request, but the required investigation records were missing.